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Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
MF Can
Surgical intervention
4 years ago
1464 views
39 likes
0 comments
16:08
Totally laparoscopic liver resection, very low anterior resection and excision of common iliac artery lymph nodes in a patient with rectal cancer and synchronous liver metastases
This is the case of a 62-year-old lady who presented with rectal bleeding four months earlier. Rectosigmoidoscopy, contrast enhanced thoraco-abdominal CT-scan, and pelvic MRI were obtained. A T3 N2 rectal adenocarcinoma 6cm proximal to the dentate line was detected. CT-scan showed that the patient had two liver metastases: one was a 4cm mass located in liver segment II and the other one 1.5cm in liver segment V. Due to the presence of suspected common iliac artery lymph nodes as determined by CT-scan, PET-CT was also obtained, which demonstrated an 18F FDG uptake in the corresponding lymph nodes. A simultaneous resection of all malignant structures was decided upon. With the patient placed in a modified lithotomy position, five trocars were inserted in the upper quadrants to start with liver resection. Left lateral sectionectomy was performed first. After resection of the lesion situated in liver segment V, which was completed without a cholecystectomy, attention was turned towards the rectal procedure. The patient was placed in a Trendelenburg position with the left side tilted upwards. Two additional trocars were placed to facilitate handling. After IMA and IMV division, a standard total mesorectal excision procedure was completed. Common iliac artery lymph nodes were then harvested. The anastomosis was performed using a double-stapling technique. A diverting ileostomy was also fashioned.
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
P Pessaux, T Urade, T Wakabayashi, D Mutter, J Marescaux
Surgical intervention
1 year ago
2203 views
7 likes
0 comments
05:51
Laparoscopic partial liver resection for hepatocellular adenoma
We report a laparoscopic partial liver resection for a large hepatocellular adenoma. This is the case of a 34-year-old patient with several small hepatic nodules. One out of three nodules was a 13cm hepatocellular adenoma, which was found to be located in Couinaud’s segments V and VI. After clamping via blood flow occlusion, parenchymal transection was performed along the outer edge of the tumor using a Sonicision™ Cordless Ultrasonic Dissection Device and an Endo GIA™ linear stapler. After liver resection, cholecystectomy was performed. The postoperative outcome was uneventful. Final pathological findings confirmed the diagnosis of an inflammatory type of hepatocellular adenoma.
Laparoscopic segment 7 resection with extracorporeal Pringle maneuver on a cirrhotic liver
This is the case of a 73-year-old man presenting with a 33mm hepatocellular carcinoma arising on a Hepatitis C virus-related well-compensated cirrhosis without portal hypertension. A laparoscopic segment 7 atypical resection was decided upon. Five ports are placed. The procedure begins with complete abdominal exploration and intraoperative liver ultrasonography. The right triangular and coronary ligaments are divided in order to mobilize the right lobe and gain access to liver segment 7. The hepatic hilum is encircled with an umbilical tape. The tape is passed percutaneously through a 24 French chest tube used as Rommel’s tourniquet to allow for a safe and fast extracorporeal Pringle maneuver. The transection plane is controlled using ultrasound. The first part of parenchymal transection is performed using Thunderbeat™ while an ultrasonic dissector (CUSA™) is used more deeply. Hemostasis is controlled with irrigated bipolar forceps and clips on major vessels. To allow for a bloodless parenchymal transection and a more precise isolation and clipping of the vessels, the hepatic hilum is clamped for 10 minutes. The chest tube is pushed towards the hilum and clamped extracorporeally. After 10 minutes, the Pringle maneuver is released for 5 minutes and then repeated for another 10 minutes until parenchymal transection is complete. No drains are placed. Operative time took 180 minutes and total blood loss was 50mL. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology confirmed a 3cm hepatocellular carcinoma without microvascular invasion. Resection margins were negative for tumor invasion.
D Citterio, C Battiston, C Sposito, M Altomare, A Benedetti, V Mazzaferro
Surgical intervention
7 months ago
1693 views
16 likes
2 comments
10:10
Laparoscopic segment 7 resection with extracorporeal Pringle maneuver on a cirrhotic liver
This is the case of a 73-year-old man presenting with a 33mm hepatocellular carcinoma arising on a Hepatitis C virus-related well-compensated cirrhosis without portal hypertension. A laparoscopic segment 7 atypical resection was decided upon. Five ports are placed. The procedure begins with complete abdominal exploration and intraoperative liver ultrasonography. The right triangular and coronary ligaments are divided in order to mobilize the right lobe and gain access to liver segment 7. The hepatic hilum is encircled with an umbilical tape. The tape is passed percutaneously through a 24 French chest tube used as Rommel’s tourniquet to allow for a safe and fast extracorporeal Pringle maneuver. The transection plane is controlled using ultrasound. The first part of parenchymal transection is performed using Thunderbeat™ while an ultrasonic dissector (CUSA™) is used more deeply. Hemostasis is controlled with irrigated bipolar forceps and clips on major vessels. To allow for a bloodless parenchymal transection and a more precise isolation and clipping of the vessels, the hepatic hilum is clamped for 10 minutes. The chest tube is pushed towards the hilum and clamped extracorporeally. After 10 minutes, the Pringle maneuver is released for 5 minutes and then repeated for another 10 minutes until parenchymal transection is complete. No drains are placed. Operative time took 180 minutes and total blood loss was 50mL. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The pathology confirmed a 3cm hepatocellular carcinoma without microvascular invasion. Resection margins were negative for tumor invasion.
Laparoscopic treatment of a hydatid cyst of the liver in children
Introduction:
Hydatid cyst is a parasitic disease caused by the Echinococcus granulosus tapeworm. Laparoscopic treatment of a hydatid cyst of the liver remains controversial and few series have been published. The aim of this work is to present a case of liver hydatid cyst in an 8-year-old girl treated laparoscopically.
Case presentation:
An 8-year-old child was admitted to our department for the management of a voluminous liver hydatid cyst. The patient underwent a thoraco-abdominal CT-scan, which concluded to a left lobe liver hydatid cyst. The laparoscopic open access is achieved at the umbilicus using a 10mm port. Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. The cyst is protected by means of pads filled with a 10% hypertonic saline solution. After we proceed to a puncture aspiration of the cyst, sterilization is achieved via injection of a hypertonic saline solution during 15 minutes, then reaspiration is performed with a Veress needle. The cyst is opened with a coagulating hook and the proligerous membrane is removed and put in a bag. The last step is the resection of the dome and the search for biliary fistula. We drained the residual cavity. The pads are removed. The Redon drain was removed on day 2 and the patient was discharged from hospital on postoperative day 3. Postoperatively, the patient was put on albendazole (10mg/kg) for one month.
Conclusion:
Laparoscopy stands for an excellent approach to the treatment of a hydatid cyst of the liver in children by respecting appropriate indications.
R Adjerid, F Sebaa, N Otsmane, A Khelifaoui
Surgical intervention
1 year ago
2088 views
11 likes
1 comment
05:13
Laparoscopic treatment of a hydatid cyst of the liver in children
Introduction:
Hydatid cyst is a parasitic disease caused by the Echinococcus granulosus tapeworm. Laparoscopic treatment of a hydatid cyst of the liver remains controversial and few series have been published. The aim of this work is to present a case of liver hydatid cyst in an 8-year-old girl treated laparoscopically.
Case presentation:
An 8-year-old child was admitted to our department for the management of a voluminous liver hydatid cyst. The patient underwent a thoraco-abdominal CT-scan, which concluded to a left lobe liver hydatid cyst. The laparoscopic open access is achieved at the umbilicus using a 10mm port. Carbon dioxide pneumoperitoneum pressure is maintained at 10mmHg. Two other 5mm ports are introduced in the right and left hypochondrium. A 0-degree laparoscope is then used. The cyst is protected by means of pads filled with a 10% hypertonic saline solution. After we proceed to a puncture aspiration of the cyst, sterilization is achieved via injection of a hypertonic saline solution during 15 minutes, then reaspiration is performed with a Veress needle. The cyst is opened with a coagulating hook and the proligerous membrane is removed and put in a bag. The last step is the resection of the dome and the search for biliary fistula. We drained the residual cavity. The pads are removed. The Redon drain was removed on day 2 and the patient was discharged from hospital on postoperative day 3. Postoperatively, the patient was put on albendazole (10mg/kg) for one month.
Conclusion:
Laparoscopy stands for an excellent approach to the treatment of a hydatid cyst of the liver in children by respecting appropriate indications.
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
J Pekolj, F Alvarez, P Huespe, J Montagné, M Palavecino
Surgical intervention
2 years ago
1385 views
80 likes
0 comments
08:17
Pure laparoscopic Associating Liver Partition and Portal vein Ligation for Staged hepatectomy (ALPPS)
This is the case of a 75-year old female patient with a medical history of bilateral mastectomy due to cancer, which occurred 30 and 15 years before referral. She was treated using adjuvant chemotherapy (tamoxifen) and radiotherapy, and had a liver-related kidney donation. The patient was found asymptomatic when she underwent a control abdominal ultrasound, which showed a 6cm hepatic mass in liver segments V and VI. A hepatic MRI was performed and showed a single liver lesion (68mm in diameter) located in the right liver lobe, and a PET-CT-scan demonstrated an increased hypermetabolic activity of the lesion without other systemic tumor dissemination. A laparoscopic right hepatectomy was scheduled. A laparoscopic surgery was performed. Laparoscopic exploration revealed multiple bilateral lesions, and an intraoperative ultrasound demonstrated a lesion in liver segment IV. An ALPPS approach was considered.
There were no complications and the patient was discharged on the third postoperative day.
Laparoscopic gastrectomy for gastric cancer after liver transplantation
It has already been demonstrated that laparoscopic gastrectomy is a safe approach for early gastric cancer. It can provide the same oncological outcomes as open gastrectomy with the benefit of fewer complications and early recovery.
Liver transplantation has a high incidence rate in the Korean population, just like gastric cancer. Additionally, South Korea has the highest incidence of this type of cancer worldwide. Patients who had received a liver transplant might benefit from a better recovery thanks to laparoscopic gastrectomy, and this approach can be performed by experienced surgeons.
Please add in the text narrative how you performed the anastomosis.
F Signorini, DJ Park, HK Yang
Surgical intervention
6 months ago
1597 views
9 likes
0 comments
09:23
Laparoscopic gastrectomy for gastric cancer after liver transplantation
It has already been demonstrated that laparoscopic gastrectomy is a safe approach for early gastric cancer. It can provide the same oncological outcomes as open gastrectomy with the benefit of fewer complications and early recovery.
Liver transplantation has a high incidence rate in the Korean population, just like gastric cancer. Additionally, South Korea has the highest incidence of this type of cancer worldwide. Patients who had received a liver transplant might benefit from a better recovery thanks to laparoscopic gastrectomy, and this approach can be performed by experienced surgeons.
Please add in the text narrative how you performed the anastomosis.
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
R Araujo, LA de Castro, F Felippe, D Burgardt, D Wohnrath
Surgical intervention
2 years ago
1844 views
166 likes
0 comments
07:47
Robotic left lateral sectionectomy in cirrhotic liver
Background: Laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Liver robotic surgery remains a work in progress and only few series reported this approach for cirrhotic patients.
Methods: This is the case of a 62-year-old man with hepatitis C virus and alcoholic cirrhosis (MELD score 10, Child-Pugh score A6) with a single lesion in liver segment III and close to its pedicle.
Results: Intraoperative ultrasound was used to confirm findings on preoperative imaging.
Parenchymal transection was made with an ultrasonic scalpel, monopolar and bipolar cautery with no Pringle’s maneuver. Linear staplers were used to control left lobe inflow and outflow. The specimen was removed through a Pfannenstiel incision. The estimated blood loss was 100mL, and the postoperative course was uneventful. Pathological findings confirmed a 2.5cm hepatocellular carcinoma, with negative margins, and a cirrhotic parenchyma.
Conclusion: Robotic left lateral sectionectomy seems to be as feasible as the conventional laparoscopic approach in selected cirrhotic patients.
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
P Pessaux, J Hallet, R Memeo, S Tzedakis, V De Blasi, D Mutter, J Marescaux, L Soler
Surgical intervention
4 years ago
1833 views
60 likes
0 comments
13:06
Laparoscopic resection of colorectal liver metastasis in segment VII with transthoracic port-site insertion using ultrasonography and augmented reality
We report the case of a laparoscopic resection in a patient presenting with a colorectal liver metastasis in segment VII of the liver, with transthoracic trocar insertion. The patient is placed in a lateral decubitus position. Four ports are introduced. After exploration of the peritoneal cavity and ultrasound examination, the intervention is begun with the control of the hepatic pedicle. The right liver is mobilized. As the position of the scope is not ideal, an improved vision is searched for using simulation tools. The subcostal port allows for an optimal view. The 5mm port is switched to a 12mm port, allowing for the placement of the scope. A 5mm port is then placed transthoracically in order to start the hepatotomy. The hepatotomy is performed under a full pedicular clamping, which takes 20 minutes. Dissection is started 2cm around the lesion. The specimen is placed in a bag and extracted through a slightly enlarged 12mm port. After hemostatic control, the tape around the pedicle is removed. The cavity is extensively cleansed. The pneumoperitoneum is reduced and one can observe that there is no bleeding. A thoracic drain is positioned at the level of the 5mm port placed transthoracically. The diaphragmatic port opening site is closed.
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
P Pessaux, R Memeo, J Hargat, S Tzedakis, D Mutter, J Marescaux, L Soler
Surgical intervention
4 years ago
2173 views
43 likes
0 comments
08:07
Laparoscopic right hepatectomy on cirrhotic liver after transarterial chemoembolization (TACE) and portal vein embolization (PVE) for hepatocellular carcinoma (HCC)
We reported the case of a 70-year-old man in whom an F4 cirrhosis and a well-differentiated hepatocellular carcinoma were evidenced and managed by a laparoscopic right hepatectomy after transarterial chemoembolization and portal vein embolization. The operation starts with the control of the hepatic pedicle. A Doppler ultrasound is performed. It will reveal the relation of the lesion with the vein. The different right hepatic structures are identified, clipped and divided. Mobilization of the right liver is then initiated. The gallbladder, which is kept in place, is used for traction purposes. Parenchymal transection is begun with the assistance of Ultracision®, Aquamantys®, and Dissectron®. The portal structure and the hepatic vein are identified. The parenchymotomy is carried on and the identification of the right hepatic vein is going to be achieved. The origin of the right hepatic vein is dissected at its upper part and its lower part, in order to encircle it with a tape and divide it with a stapler. Once completed, the medial part of the right triangular ligament is further divided. Mobilization is continued on the same part from both sides, changing traction. The right liver is placed in a bag and removed. The cavity is cleansed. The hemostasis and biliostasis are controlled on the transection.
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
I Boškoski, RA Ciurezu, I Crisan, L Guerriero, F Habersetzer, M Bouhadjar, D Mutter, J Marescaux
Surgical intervention
2 years ago
1635 views
69 likes
0 comments
09:31
Anastomotic biliary stricture after liver transplantation
Biliary stricture is the most frequent complication after liver transplantation, and ranges from 5 to 32%. Biliary strictures in transplanted patients can be anastomotic and non-anastomotic. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the first-line treatment modality for anastomotic biliary strictures and in selected cases of non-anastomotic biliary strictures. Anastomotic biliary strictures arise at the site of the choledocho-choledochostomy. ERCP with multiple plastic stent placements is the first-line treatment of anastomotic biliary strictures, with long-term success rates ranging from 90 to 100%. Also covered self-expandable metal stents can be used for dilation of these strictures, but not routinely.
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.
P Pessaux, J Hallet, R Memeo, D Mutter, J Marescaux
Surgical intervention
5 years ago
1925 views
59 likes
0 comments
10:01
Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases
We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance.
The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.